Abstract
Patients with a solitary kidney undergoing nephrectomy
represent a uniquely high-risk group in whom anaesthetic
management directly influences renal and overall perioperative
outcomes. With the increasing use of robotic-assisted
techniques such as the da Vinci Surgical System,
anaesthesiologists must address procedure-specific
physiological challenges of pneumoperitoneum and lateral
positioning, restricted access after docking, and potential
warm ischemia - all of which may compromise renal perfusion.
Preoperative assessment must focus on renal reserve,
optimization of volume status and risk stratification for
acute kidney injury. Intraoperative management included
balanced general anesthesia with endotracheal intubation,
invasive arterial pressure monitoring and strict haemodynamic
control to maintain adequate mean arterial pressure.
Ventilatory adjustments were made to counteract the
physiological effects of carbon dioxide pneumoperitoneum.
Keywords: Solitary kidney, Partial nephrectomy, da
Vinci surgical system, Robotic nephrectomy
Introduction
A solitary kidney may be congenital (renal agenesis), acquired
(post-nephrectomy), or functionally solitary due to pronounced
contralateral renal impairment. In such patients, the
preservation of residual renal function assumes critical
importance, as any perioperative insult may precipitate acute
kidney injury (AKI) and long-term chronic kidney disease (CKD)
[1]. The surgical management of renal masses in this
demographic thus represents a distinctive clinical challenge,
necessitating a delicate equilibrium between optimal surgical
dissection and nephron preservation [1,2].
Robotic-assisted nephrectomy performed using platforms such as
the da Vinci Surgical System has increasingly become an
established approach for both partial and radical nephrectomy
[3,4]. Compared with open surgery, robotic techniques provide
enhanced visualization, improved dexterity, reduced blood
loss, and shorter hospital stay [3,4]. Partial nephrectomy is
generally recommended in patients with a solitary kidney to
preserve nephron mass and reduce the risk of long-term renal
dysfunction, consistent with guidance from the American
Urological Association and the European Association of Urology
[1,2]. However, complex tumors, unfavorable anatomy, or
intraoperative findings may necessitate radical nephrectomy
despite the increased risk to renal reserve [1,2]
From an anaesthetic perspective, robotic nephrectomy
introduces significant physiological challenges related to
carbon dioxide pneumoperitoneum and lateral positioning [5].
Pneumoperitoneum increases intra-abdominal pressure, reduces
venous return, alters renal blood flow, and may impair
glomerular filtration rate [5]. Lateral decubitus positioning
and prolonged operative duration further influence
cardiopulmonary dynamics and tissue perfusion [5]. During
partial nephrectomy, temporary renal hilar clamping and warm
ischemia may contribute to postoperative renal dysfunction,
making maintenance of adequate mean arterial pressure and
oxygen delivery critical [4]. Restricted access to the patient
after robotic docking necessitates meticulous preparation,
secure airway management, and reliable vascular access to
ensure patient safety [3,5].
In patients with a solitary kidney, anaesthesia therefore
plays a central role in perioperative renal protection [4].
Strategies including preoperative optimization, avoidance of
nephrotoxic agents, goal-directed fluid therapy, and strict
haemodynamic control are essential to minimize perioperative
renal injury [4]. Thus, anaesthetic management is not merely
supportive but integral to preserving renal function and
improving outcomes in this high-risk surgical population [4].
Case report
An elderly gentleman known a case of COPD - emphysema since
childhood, hypertension for the past 1 year presented with
complaints of abdominal pain which was associated with
backpain radiating to his leg. General and Systemic
examination were within normal limits. On assessment of
airway, mouth opening was normal, with adequate neck movements
and the Mallampatti grade was 2.
Lab values showed Hb - 13.4gm%, platelet count -2.65 lakhs/mm
3,
aPTT was 10.3/10.4 with an INR value of 0.99. Other blood
investigations showed S.Creatinine 1.3 and serum electrolytes
were within normal limits. The electrocardiogram taken
showed normal sinus rhythm with T inversion in lead aVL.
Echocardiogram showed no regional wall motion abnormality,
normal left ventricular systolic function, left ventricular
diastolic dysfunction, and LV ejection fraction of 64%. Chest
X-ray was taken which showed tubular shaped heart, Bilateral
hyper inflated lung fields with increased bronchovascular
markings. CT Thorax taken showed mild to moderate cylindrical
bronchiectasis involving apical, anterior and posterior
segments of right upper lobe and basal segments of right lower
lobe. Mild cylindrical bronchiectasis noted in medial segment
of right middle lobe.
After preoperative optimization including incentive
spirometry, nebulization with Levosalbutamol and Fluticasone,
one sachet of Carboload in 250ml of water orally on the
previous night and morning two hours before surgery. He
was taken up for procedure under General anaesthesia. A high
risk informed consent was taken informing postoperative
ventilation, postoperative dialysis.
He was premedicated with injection Metoclopramide 10 mg IV and
injection Pantoprazole 40 mg IV, Midazolam 1mg and
Dexamethasone 8mg IV. In the operation theatre, all standard
ASA monitors including pulse oximeter, 5 lead ECG and
noninvasive blood pressure was attached. Room air saturation
was 98% under room air. Oxygen was initiated via Hudson's face
mask at 5L/min.
He was induced with injection Propofol 150 mg, injection
Fentanyl 100mcg, Vecuronium 8mg and intubated with 8 mm
internal diameter flexometallic cuffed endotracheal tube under
Sellicks maneuver using McCoy Laryngoscope, CL grading 4 was
noted. Cuff was inflated to a pressure of 22 cm of H
2O
and fixed it at 21cm at the anterior incisor level. A suction
catheter of size 14G was inserted to deflate the stomach.
Patient was mechanically ventilated with (pressure
controlled-volume guaranteed (PC-VG) mode using closed circuit
and end tidal carbon dioxide was monitored. The ventilatory
settings were adjusted as tidal volume-400ml, RR - 14/minute,
PEEP - 5 cm H
2O, FiO
2 - 55%. Maintenance
was carried out using sevoflurane,oxygen, air, Paracetamol one
gram IV at induction and fentanyl infusion at 50microgram/hr,
ensured adequate depth.
Left radial artery cannulation was performed for invasive
blood pressure (IBP) monitoring, and a right internal jugular
vein catheter (Certofix protect 7 French triple lumen)
was secured. A transdermal Fentanyl patch releasing 25mcg/hour
was placed on the chest at the end of procedure. A Bair Hugger
and a hotline fluid warmer and an oral temperature probe were
also kept in place. Deep Vein Thrombosis (DVT) prophylaxis
during intra op period was by intermittent pneumatic
compression devices which was continued in the post op period
also.
Arterial blood gas analysis (ABG) done following induction
which showed normal values. Fluid requirements were met with
warm balanced crystalloid solutions such as Sterofundin
The surgical procedure was uneventful, with an approximate
blood loss of 250ml. Intraoperatively, the patient had a pulse
rate of 70-76/min and a systolic BP fluctuating which was
managed with Noradrenaline and NTG infusion which was titrated
accordingly. During the surgery antibiotics were repeated
after 4hrs, mannitol 20 gm IV, methyl prednisolone 125 mg IV,
Furosemide 20 mg IV was given. N acetyl cysteine infusion (10
gram in 50 ml) at 2 ml/hr IV was started. Specimen was removed
through a 4-6 cm surgical incision. A USG guided unilateral
lateral transverse abdominal plane (TAP) block with
ropivacaine 0.2%, 20 ml was given to cover the somatic pain
from the surgical incision. After the surgical procedure,
patient was reversed with Suggamadex 200mg IV. Postextubation
he was haemodynamically stable and was shifted to
Postoperative ICU.
Discussion
Patients with a solitary kidney undergoing robotic partial
nephrectomy require careful perioperative management because
preservation of renal function is critical and the risk of
postoperative acute kidney injury (AKI) remains significantly
higher compared with patients with bilateral kidneys. Recent
studies have shown that although robot-assisted partial
nephrectomy provides favorable long-term renal functional
outcomes, solitary kidney patients remain more vulnerable to
postoperative AKI, particularly when warm ischemia time
exceeds 25 minutes or when baseline renal function is reduced
[6].
Furthermore, contemporary studies indicate that robotic
partial nephrectomy is both a safe and effective surgical
intervention, efective approach for tumors in solitary
kidneys, offering advantages such as improved operative
precision, reduced complications, and preservation of renal
function when compared with traditional laparoscopic
techniques. [7]
Robotic nephrectomy utilizing advanced systems such as the da
Vinci Surgical System confers numerous surgical advantages,
including enhanced visualization, superior precision, and
diminished intraoperative blood loss. Nevertheless, the
establishment of carbon dioxide pneumoperitoneum and the
necessity for lateral decubitus positioning engender
significant physiological alterations. Elevated
intra-abdominal pressure may attenuate venous return and
cardiac output while concurrently augmenting systemic vascular
resistance, potentially jeopardizing renal blood flow and
glomerular filtration rate. These physiological ramifications
are particularly consequential in patients with a solitary
kidney, wherein the preservation of renal perfusion is
paramount.
Invasive hemodynamic monitoring plays a critical role in the
anaesthetic management of these cases. Placement of an
arterial line allows continuous blood pressure monitoring and
facilitates frequent arterial blood gas analysis during
prolonged procedures. Continuous monitoring enables early
detection of hypotension or haemodynamic fluctuations that may
adversely affect renal perfusion. Maintaining adequate mean
arterial pressure is essential to ensure sufficient renal
blood flow, particularly during pneumoperitoneum or periods of
surgical manipulation [4]. In addition, central venous
catheterization may be useful for administration of vasoactive
medications, fluid management, and assessment of volume status
during major laparoscopic or robotic procedures with potential
hemodynamic instability [8].
Patient positioning is another key consideration in robotic
nephrectomy. The lateral decubitus position combined with
robotic docking restricts access to the patient once the
surgical system is engaged. Therefore, careful positioning and
padding before docking are essential. Adequate padding of
pressure points such as the head, dependent shoulder, elbows,
iliac crest, knees, and ankles helps prevent nerve injuries
and pressure-related complications during prolonged surgery.
Particular attention should be paid to protecting the brachial
plexus, peroneal nerve, and ulnar nerve, which are vulnerable
in the lateral position [9]. Proper alignment of the spine and
use of gel pads or foam supports can further reduce the risk
of pressure injuries.
Prolonged operative duration and reduced patient mobility
during robotic surgery also increase the risk of venous
thromboembolism (VTE). The use of intermittent pneumatic
compression devices, such as calf pumps, is therefore
recommended intraoperatively to promote venous return and
reduce venous stasis in the lower limbs [10]. These devices
are particularly useful during lengthy procedures in the
lateral position, where venous pooling in dependent limbs may
occur.
Fluid management remains another critical component of renal
protection. Both hypovolemia and excessive fluid
administration can adversely affect renal perfusion and
postoperative outcomes. Goal-directed fluid therapy guided by
invasive monitoring or dynamic parameters can optimize
intravascular volume and maintain adequate organ perfusion.
Avoidance of nephrotoxic medications and maintenance of
normothermia also contribute to minimizing perioperative renal
injury [4].
Finally, limited access to the patient after robotic docking
necessitates thorough preparation before the start of surgery.
Securing the airway, ensuring reliable intravenous access,
confirming appropriate monitoring, and checking all pressure
points are essential steps prior to docking of the robotic
system. Such meticulous preparation helps ensure patient
safety throughout the procedure.
Overall, anaesthetic management plays a pivotal role in
optimizing perioperative outcomes in patients with a solitary
kidney undergoing robotic nephrectomy. Careful haemodynamic
monitoring, meticulous positioning and padding,
thromboprophylaxis with mechanical devices, and
renal-protective anesthetic strategies are crucial to
minimizing complications and preserving postoperative renal
function.
Conclusion
Robotic nephrectomy in a patient with a solitary kidney
presents significant anaesthetic challenges in which renal
preservation is paramount. The physiological effects of
pneumoperitoneum, lateral positioning, potential hemodynamic
instability, and restricted access after docking of the da
Vinci Surgical System demand meticulous preparation and
vigilant intraoperative management.
A proactive, renal-protective anaesthetic strategy -
emphasizing optimization of volume status, strict maintenance
of mean arterial pressure, goal-directed fluid therapy,
avoidance of nephrotoxic agents, and close postoperative
monitoring - is essential to minimize the risk of acute kidney
injury. In such high-risk cases, anaesthesia extends beyond
supportive care and becomes central to preserving renal
function and ensuring favorable perioperative outcomes.
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